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Report of the County Medical Officer—Education. 215
The schools are now better known, and the value of the work undertaken therein is realised, so that
there is a far greater readiness on the part of medical men and women to advise the sending of
children to such schools instead of giving certificates recommending absence from school. Coincident
with this change there has been far less resistance on the part of the parents to the attendance of their
children at special schools, particularly during the earlier years of school life. Every school child
has been seen at least once as a result of the more detailed examination undertaken since 1909, so that
there should be no large reserve of uninspected children to draw upon, and it may be anticipated that
the number of defective children will now be subject only to seasonal variations, and the increases
hitherto noted are not likely to continue so long as the present conditions and regulations exist.
The condition of admission to these schools has at all times been that the children are, by
reason of physical defect, incapable of receiving proper benefit from the instruction in an ordinary
public elementary school, but not incapable, by reason of such defect, of receiving benefit from
instruction in a certified special class or school. The standard regarded as qualifying for admission
has not varied, but the opposition of outside medical practitioners to the admission of defective
children to special schools has very largely disappeared. Formerly cases of tubercular joints, which
had to remain for long periods in constrained apparatus, although able to get about to some extent,
were naturally allowed to attend school from the start. In cases of heart disease, chorea, and similar
chronic affections liable from time to time to acute exacerbations, a period had to elapse before public
opinion had been sufficiently educated to allow confidence to be reposed in the new school conditions,
but in due course children were admitted who formerly received no education.

The above comparison shows that the chief decrease has been in cases of tubercular disease,
with regard to which it is probable that a more uniform level has now been reached. There has been
some increase in the number of cases crippled by paralysis or deformity, and a material decrease in
the numbers of children who were delicate, convalescent from acute illness or operation, or admitted
to the physically defective school temporarily for observation. The chief increase has been in the
case of heart disease. As pointed out in the annual report for 1912, these cases fall into two
categories.
The first class includes the important group of children who have no organic valvular lesion,
but whose heart muscle has been weakened temporarily as a result of some acute illness, usually of
an infectious nature, such as scarlet fever or diphtheria. After severe attacks of such illnesses,
convalescence is protracted and sudden violent exertion may be attended with serious danger to
health or even to life, and it is necessary that the re-establishment of school routine should be slow.
Many physicians are inclined to disallow school attendance at an ordinary school, where the children
would be exposed to the exertion of games and stair-climbing, and the value of the special schools
is now generally recognised by the medical staff of hospitals, who, from time to time, suggest that
certain children, though unfit for the ordinary school, might be admitted to a school for the physically
defective. In many cases these children, who constitute a small minority of the total heart cases
in the special schools, are able to return to the ordinary schools after a time ; but the return thereto
depends on the age at which they are admitted to the special schools.
The second class consists of children suffering from definite organic, usually valvular, lesions
of the heart. This group must be sub-divided into two groups, those with congenital lesions and
those in whom the lesion has been acquired as a sequel to some serious illness, such as chorea,
rheumatic or scarlet fever. In some cases it is impossible to state with certainty the category in
which a given child should be placed. The ultimate prognosis in congenital cases is unfavourable,
but a considerable proportion of the children survive for many years after the school period, and the
education they receive not only adds to their happiness, but often enables them to contribute in some
measure to their own support by means of various light home occupations.
Cases of acquired heart disease were found to constitute 86 per cent. of those of an organic
nature, the chief cause being a preceding attack of rheumatism or chorea. In connection with these
cases, two factors are of paramount importance—the prevention of fresh attacks of rheumatism
and chorea which would be accompanied by further damage to the heart, and the physical education
of the damaged heart muscle to enable it to overcome the mechanical difficulties associated with
injured heart valves.
The risk of recurrence of rheumatism and chorea can be appraised only in general terms. The
more remote the original attack the less likely a recurrence, and the younger the child at the date of
the first attack the more likely is it to be subject to recurrences. Exposure to damp predisposes to